What are compulsions?

Compulsions have been defined as uncontrollable urges to say or do something often without an obvious reason. Compulsions are different for everyone, they can be thoughts or behaviours, and can vary in their intensity.

There are many common activities that can develop into compulsions such as those playing a role in addictions. When people have an addiction, they experience an intense and uncontrollable craving for a substance or activity, as an addiction develops, it often will involve a feeling of compulsion to take an addictive substance, such as alcohol or drugs, or to carry out an addictive behaviour such as eating, shopping, internet use or gambling, because consuming that substance or engaging in that behaviour produces rewarding feelings of pleasure despite their harmful consequences. Some people even talk, lie or exercise compulsively.

Compulsions, according to a growing body of scientific evidence, are a response to anxiety, and are often associated with other conditions such as:

• Generalised Anxiety Disorder (GAD)
• Post-Traumatic Stress Disorder (PTSD)
• Body Dysmorphic Disorder (BDD)
• Impulse-Control Disorders such as Kleptomania or Pyromania

Compulsions are also a symptom of obsessive-compulsive disorder (OCD), however the compulsive thoughts and / or behaviours seen in some of the conditions outlined above are not part of OCD, they are more likely to be connected to either anxiety or addictive problems.

In this article we will look at compulsive thoughts and behaviours particularly as they relate to obsessive-compulsive disorder (OCD), and treatments and strategies that are used to help deal with compulsions in OCD.

What are compulsive thoughts?

Compulsive thoughts are unwanted thoughts, images, or urges that repeatedly enter your mind that may cause anxiety or distress. It can be common to have intrusive compulsive thoughts about doing or saying things, and many people have these thoughts. For most people these thoughts pass out of their minds as quickly as they appear, whist for others, it can be hard to shrug these thoughts off. Often these thoughts are difficult to control and for some people can lead to compulsive behaviours.

These sudden, involuntary ideas or urges are spontaneous thoughts that may lead a person towards immediate actions without considering the consequences. Compulsive thoughts can for example include an unexpected urge to buy something unnecessary, a sudden desire to speed on the motorway, or the impulse to say something inappropriate in a social setting. These compulsive thoughts often over-ride rational thinking and can significantly influence behaviours, at times leading to immediate action. Often these impetuous actions that emanate from compulsive thinking can result in negative outcomes such as relationship difficulties, problems with authority / legal consequences, or financial hardships.

Compulsive thoughts can be associated with OCD, but not always. In OCD, these compulsive thoughts are also known as obsessions. People with OCD experience unwanted obsessions which take the form of persistent and uncontrollable thoughts, although obsessions can sometimes be persistent images, impulses, worries, fears or doubts or a combination of all these. Obsessions are typically accompanied by intense and uncomfortable feelings such as fear, disgust, uncertainty, and / or doubt, or a feeling that things have to be done in a way that is “just right.” People with OCD usually struggle with obsessions, compulsions, or both daily. The compulsive obsessive thoughts trigger compulsive behaviours or mental rituals that are meant to ease the distress.

These thoughts and compulsions are disruptive and disturbing for the person experiencing them and produce fear, doubt, and other negative feelings even if the person diagnosed with OCD recognises that the thought doesn’t make any sense.

Compulsive thoughts and the rituals that accompany them can be time-consuming and may make everyday activities difficult for a person with OCD.

What are compulsive behaviours?

Compulsive behaviours come in many forms, and include activities for example but not limited to hoarding, shopping, gambling, substance abuse, even self-harm, which in some cases can become debilitating or even dangerous. The underlying cause and emotional drive for these compulsive behaviours are different depending upon reason for the behaviour.

Compulsive behaviours are often be driven by habit, reward, impulse, or emotional or sensory needs and can be experienced by many, many people at some point in their lives. Although more often associated with OCD, compulsive behaviours can occur in a large group of disorders including but not limited to addictions, Tourette syndrome, autism, body dysmorphic disorder, hoarding, and impulse control disorders such as Dermatillomania, or Trichotillomania.

Stress and anxiety are the typical psychological triggers for many who engage in compulsive behaviours, especially behaviours and activities such as shopping, gambling, or substance abuse, where logical thinking is replaced by a need for quick comfort, or where depression has developed and the person might assume a “who cares” attitude.

In OCD, compulsive behaviours are the physical or mental actions performed to cope with the distress caused by their compulsive thoughts or obsessions, or to prevent something bad from happening. People with OCD feel driven to do something repetitively, known as rituals. These behaviours may appear to be odd or unnecessary to other people, but they provide temporary relief from distress for the individual who performs them.

Compulsive behaviours in OCD may be obvious, overt behaviours such as but not limited to cleaning and hand washing, checking, ordering and arranging, doing the same thing many times, or they may not be at all obvious, they are more convert behaviours such as but not limited to repeating words or counting in your head, or thinking neutralising thoughts to counter the obsessive thoughts.

This type of OCD is known as pure O OCD, the name comes from the idea that this type of OCD involves only obsessions. However it generally still involves compulsive rituals, it is just that the compulsions happen mentally instead of physically. In all forms of OCD, these rituals, while seemingly illogical, are done to neutralise the fear or uncertainty associated with the obsessive thought.

What are the signs of obsessive compulsive disorder?

Obsessive-compulsive disorder (OCD) is a mental health condition that affects approximately 1.2% of the UK population that means that around 12 in every 1,000 people have OCD and recent research suggests that OCD is slightly more prevalent in women than in men. The condition can develop at any age, but it often begins in childhood or adolescence, with peaks around the ages of 8 – 12 years and in the late teens or early adulthood.

OCD is a widely misunderstood condition with many misconceptions about it, such as that OCD is just a minor personality quirk or preference, and that everyone can be “a little bit OCD.” Whilst it is true that most people can have obsessive thoughts and / or compulsive behaviours at some point in their lives, it does not mean that they have OCD. Rather, OCD is a serious and often debilitating mental health disorder that can affect people of all ages and walks of life, and occurs when a person gets caught in a cycle of obsessions and compulsions.

Although OCD can be different for everyone, it is characterised by a cycle of obsessions or thoughts and compulsions or activities. Having the same distressing compulsive thoughts and urges that feel outside of the person’s control again and again can be a symptom of obsessive compulsive disorder (OCD). The thoughts or urges (obsessions) provoke a feeling of intense anxiety or distress. As a response to the obsessive thought pattern, the person feels driven to perform repetitive behaviours or mental acts (compulsions), this compulsive behaviour relieves the anxiety for a short while, however, the obsession and anxiety soon returns, and the cycle begins again.

The themes of someone’s compulsions are normally, but not always related to their obsession, often there is a logical connection where the compulsions aim to alleviate anxiety associated with an obsession such as cleaning to reduce a fear of dirt however, compulsions can also be unrelated to the specific obsession. There are people who perform compulsive behaviours who cannot identify a specific obsession, their underlying fear or compulsive thought might be unclear, subconscious, or hard to verbalise, however they perform rituals to relieve feelings of dread or tension.

The diagnostic criteria for OCD is set out in the Diagnostic and Statistical Manual of Mental Illnesses (DSM-5) but generally the signs that indicate that someone may be experiencing the condition are that their obsessions and compulsions are unwanted and persistent and cause distress, that the compulsive behaviours are linked to reducing anxiety or preventing something bad from happening, that they are taking up a significant part of the person’s time and interfere with their daily life, and that they negatively affect their personal life and relationships.

Symptoms of OCD may not remain the same all the time. For some people, they may fluctuate depending on their stress levels or other factors. For other people the symptoms may get better or worse as they age. In severe cases, OCD can be considered a disability under the Equality Act 2010 which defines disability as having a physical or mental impairment that has a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities.

What are the causes of obsessive compulsive disorder?

Research shows that OCD is likely to result from a combination of biological, psychological, and environmental factors, although the condition is complex and the causes are not fully understood.

Environment – Research suggests that stressful life events such as bullying, abuse, neglect, or traumatic life experiences can increase the risk of developing OCD and may trigger or exacerbate OCD in a significant number of individuals. This may be because stress can increase anxiety levels, which in turn leads to a greater need for reassurance or ritualistic behaviours that provide a temporary sense of relief. Individuals with OCD may be more sensitive to stress and have a lower threshold for tolerating stress, making it easier for stress to trigger or worsen their OCD symptoms. Stress can also intensify existing OCD symptoms, making obsessive thoughts and compulsions more frequent and severe.

PANDAS – there is a rare subtype of childhood OCD known as paediatric autoimmune neuropsychiatric disorder associated with strep (PANDAS) that occurs when strep bacteria causes an immune reaction, resulting in OCD-like symptoms. Children with PANDAS seem to have dramatic ups and downs in the severity of their OCD and have a very sudden onset or worsening of their symptoms, followed by a slow, gradual improvement. Children with PANDAS can go on to have OCD in adulthood, but this isn’t always the case.

Genetics – There is compelling evidence that OCD has a genetic basis. A study with twins showed that genetics had a stronger role than environmental factors in the expression and development of OCD and that a shared environment such as a home, did not significantly impact OCD expression. A 2023 systematic review and meta-analysis found that about 50% of the risk for OCD is attributed to genetics. Research has also found that genetics plays a role in the variability in the severity of symptoms that people with OCD experience.

Family history – Research published in the journal Psychiatric Clinics of North America supports the opinion that there can be familial transmission of OCD. In other words, OCD can run in families, between 10% – 20% of children who have a parent with OCD will develop OCD themselves, however a family history may only increase the risk of developing OCD, it is not a guaranteed outcome. It is more likely that a combination of genetic and environmental factors will determine whether or not a person develops OCD.

The brain – OCD has been linked to neurotransmitter imbalances and abnormalities or differences in specific brain regions. Neurotransmitters are chemical messengers that transmit signals between nerve cells (neurons) and other cells, enabling communication in the nervous system. Neurons use serotonin to project to various parts of the nervous system, as a result, serotonin is involved in functions such as sleep, memory, appetite, mood and others.

It is also produced in the gastrointestinal tract in response to food. Researchers have found that an imbalance in neurotransmitters can play a role in OCD, with strong evidence that serotonin is implicated. Differences in the neurotransmitters dopamine, glutamate, and GABA can also contribute to the progression of OCD. Images of the brain have revealed some differences between people with OCD and those without it, but these differences are small and not consistently observed, and researchers are unsure whether these differences cause OCD or are caused by OCD. Research has shown that over-activity in the parts of the brain affected by OCD includes:

• The orbitofrontal cortex (OFC) which is involved in shaping our thoughts, memories, emotions, and intuitive / gut feelings, this is also known as visceral states
• The anterior cingulate cortex (ACC), this helps us detect or predict errors, and plays a role in attention, motivation, memory, and emotion
• The thalamus, this sends signals to the brain that relate to physical movement and sensation
• The basal ganglia, this helps us plan and carry out actions and behaviours

Temperament – research has shown that someone’s natural disposition or personality traits can be a contributing factor to a person developing OCD especially under stress, and the DSM-5 lists temperament as risk factor of developing the condition. Individuals with higher neuroticism scores may be more susceptible to OCD as they have a tendency toward negative emotions such as anxiety and depression. Perfectionism is a character trait and is not the same thing as OCD which is a mental health condition, however, perfectionism and the fear of getting things wrong can fuel obsessive compulsive thoughts and behaviours, which may develop into OCD behaviours.

Common types of OCD compulsions

When a person is diagnosed with OCD it means that they experience obsessions, compulsions, or both. As we have seen, obsessions are intrusive and distressing thoughts urges, or images that cause fear, distress, anxiety or disgust, and that are difficult to manage often interfering with daily life. Compulsions are the physical or mental repetitive behaviours or rituals that a person with OCD engages in to help to relieve the anxiety that their obsessions cause.

Types of obsessions and compulsions may vary between people with OCD however researchers and the DSM-5 identify a number of common themes associated with OCD obsessions and a number of commonalities to the compulsive behaviours or rituals that are employed to generate some, albeit temporary, relief. These include but are not limited to:

Cleaning, contamination and germs

This OCD obsession usually focuses on the persistent fear of being exposed to germs or other perceived contaminated substances. Obsessions may include for example, persistent worry about germs or sickness, intrusive thoughts about feeling dirty or unclean either physically or mentally, fears of contamination by disease or infection, concerns about being contaminated by body fluids such as blood etc.

One of the most recognised OCD compulsions associated with contamination obsession is frequent and excessive handwashing rituals, but this can also include excessive showering, bathing, tooth-brushing, grooming, or toilet routines. Other common contamination compulsions include but are not limited to urges to clean or get rid of items that could be contaminated or dirty, recurrent cleaning rituals, avoiding particular places, people or situations to avoid contamination.

Order and symmetry

This OCD obsession usually focuses on how things look or are arranged, needing things to be orderly and balanced and obsessions may include for example, feeling anxiety or extreme distress if things aren’t in a certain order, continuous feelings of fear and dread that something bad will happen if an item is out of place or if there are odd numbers of items.

Compulsions commonly associated with order and symmetry obsessions can include but are not limited to checking that items are arranged “just right” and constantly adjusting items until they feel aligned, arranging items so that they are perfectly displayed or aligned in the same direction, need to repeat counting rituals such as counting to a specific number a certain number of times, touching parts of your body multiple times or in a specific order, tapping or touching specific things when you enter and leave a room.

Harm or violence

This OCD obsession can focus on harm to oneself or to objects or possessions, or being abusive or violent to others, obsessions may include for example unwanted images of violence and aggression, fear your thoughts may cause a disaster or accident, fears you may harm yourself or a loved one inadvertently, fear of losing control and acting on violent impulses.

Compulsions commonly associated with harm or violence can include but are not limited to constantly checking switches, cars, doors, taps, locks etc. to prevent danger or accidents, avoiding particular places, people or situations to avoid causing harm, hoarding items you deem to be dangerous for fear they may cause harm if disposed of, attempting to ‘neutralise’ an obsessional violent thought by counting or performing other forms of ritual.

Responsibility

This OCD obsession can focus on a person being concerned about the repercussions of their actions or non-actions may have on people or things that they feel responsible for, obsessions may include for example fear that an action that they did or didn’t take could cause harm, fear of failing to prevent harm from happening, doubts about locking doors or turning off appliances, fearing they will forget, or have forgotten something important, images of driving at speed or dangerously.

Compulsions commonly associated with responsibility obsessions can include but are not limited to repeated checking or mental rituals to feel safe or sure, a constant need to seek reassurance, frequent reviewing of daily activities whether mentally or physically retracing their steps, locking, unlocking, and relocking doors or turning appliances off, on and then off again.

Sexual or moral

This OCD obsession usually focuses on unwanted thoughts or mental images related to sex, sexual behaviours, sex / gender identity or morality issues, obsessions may include for example fears about saying or doing something inappropriate or wrong, experiencing sexual fantasies and impulses that might be inappropriate, fear of being rude, or using discriminatory or obscene language, images of stealing something or breaking other laws, fears that commonplace behaviours are wrong or immoral.

Compulsions commonly associated with sexual or morality obsessions can include but are not limited to seeking reassurance from friends, family members, or religious figures, avoiding triggers or any situation likely to lead to a sexual or immoral compulsion, persistent questioning sexual orientation, desires, or sexual interests, replacing a bad thought with a good thought, checking and rechecking memories, praying to prevent immoral thoughts or actions.

As with obsessions, many of the most common compulsions that we have highlighted usually have themes, such as:

• Washing and cleaning
• Checking
• Counting
• Touching
• Ordering
• Following a strict routine
• Demanding reassurance

Getting treatment for OCD compulsions

As previously stated, OCD usually begins in the teen or young adult years, but it can start in childhood, and in some cases may not become obvious until the person reaches adulthood. If you are experiencing obsessions and compulsions that affect your quality of life, or are concerned about someone else, a GP should be the first point of contact as they will be able to perform an initial screening for OCD, assess the symptoms and refer the person for further help if needed. Anyone unable to access a GP appointment can contact NHS 111.

It may help to note down the ways your OCD is affecting your life to be able to discuss your symptoms and what you have been experiencing fully with your GP, they can then inform you about your treatment options. A GP can make a referral for therapy and / or prescribe the recommended medication if required. You may be referred to a specialist mental health team who can work with your GP to find the right treatment plan.

There are several treatments that can be prescribed to help to manage OCD however, it is unlikely that OCD can be cured completely, but with a good treatment plan, the symptoms can become much more manageable so that they don’t control your life. Usually OCD treatment consists of a combination of cognitive behavioural therapy (CBT), exposure response prevention (ERP) and medication.

CBT is a type of talking therapy that helps individuals manage mental health problems by changing their thoughts, feelings, and behaviours. CBT helps individuals understand their obsessions, gradually confront situations they avoid, and helps them to resist compulsive behaviours.

ERP has been shown to be an effective treatment for OCD as it helps the person to practice confronting and accepting the thoughts, images, objects, and situations that make them anxious and provoke their obsessions, and to learn to resist the urge to carry out compulsions.

A person can also refer themselves directly to an NHS talking therapies service.

Medications that may be prescribed for OCD either on their own or alongside talking therapy include Selective serotonin reuptake inhibitors (SSRIs) this is a type of antidepressant however research has shown that it can also help to treat OCD. If a person is unable to take SSRIs or they are found not to be effective, a GP may offer a tricyclic antidepressant such as Clomipramine.

Engaging in mindfulness techniques such as mindful breathing, meditation, or yoga can help to reduce overall stress and anxiety, which can trigger obsessions and compulsions.

The treatment that you may be offered for OCD will depend on how significantly OCD is affecting your life and how much distress it is causing you. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practice in healthcare including treatment for OCD.

Conclusion

OCD can be a serious problem if left untreated, but with the right diagnosis, treatment strategies and support, it can be treated very effectively through psychological and medical therapies.